Hipcast
Hipcast
When Surgery Isn’t the Path: Understanding Non-Operative Care After Hip Fracture
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In this episode of Hipcast, we’re joined by Dr Hannah Seymour and Dr Carla Davies, geriatricians at Fiona Stanley Hospital, alongside Pip, who shares her experience as a family member of a patient managed non-operatively after hip fracture.
Together, we explore what non-operative hip fracture care looks like in practice — who it may be appropriate for, how decisions are made, and how clinicians can support patients and families when surgery is not the right path.
Pip brings an important consumer perspective, highlighting the impact of communication, compassion and clarity during a difficult and emotional time.
Hannah and Carla discuss the clinical and research context, including decision-making in frailty and advanced illness, outcomes for patients managed without surgery, and practical ways clinicians can improve care.
Importantly, the conversation reinforces that non-operative management does not mean “no care”. It requires active, thoughtful and person-centred care focused on comfort, dignity and what matters most to the patient.
Resources:
Non-operative versus operative management of hip fractures in Australia and New
🎙️ Hipcast is hosted by Dr Niamh Dove and produced by the Australian and New Zealand Hip Fracture Registry, dedicated to improving outcomes and experiences for people with hip fracture and those who care for them.
Hello and welcome to Hipcast, the podcast here to improve hip fracture care. I'm your host, Dr. Neve Dove. Today we're exploring current practice of non-operative management of hip fractures across Australia and New Zealand, a topic that is incredibly important for a subset of patients and their families. I'm joined by three guests bringing both clinical and lived experience perspectives. Dr. Hannah Seymour, an orthogeriatrician from Fiona Stanley Hospital in Western Australia. Dr. Carla Davies, also an geriatrician from Fiona Stanley Hospital, whose trainee project explored outcomes for patients managed non-operatively after hip fracture. And Pitt Brennan, a systemic health consumer advocate for the past 25 plus years and a carer advocate who joins us today to share her experience as a daughter of her mother's hip fracture journey. We at the Australian and New Zealand Hip Fracture Registry acknowledge the Gadigal people of the URI Nation and the Wajuknonga people as the traditional custodians of the lands on which we are recording today and pay our respects to elders past, present, and emerging. We extend that respect to the Aboriginal, Toroshi Islander and Maori people joining us today and listening on the podcast. So I thought to begin, welcome everyone. Thank you for joining us today. It would be really great to open up with Pip's perspective in terms of thank you again for being willing to join us, Pip, but to start, would you feel comfortable sharing a little about your mother's hip fracture experience and what the journey looked like from your perspective? Thank you so much.
SPEAKER_01I think you know I I'm obviously going to share my journey both as a daughter but also as a systemic health advocate because I would be watching things unfold in real time and also putting them through my lens as a systemic advocate. And interestingly for me, I've been a consumer advocate for a long time, but I learned so much about being a carer advocate that really helped me, I guess, become a more nuanced consumer advocate and understanding that it's yeah, it there's a lot, there's a lot to it. So my mother was the grand old age of 97, nearly 98. And uh I would I would say be fair to say the quality of her life in her last year was not fantastic. She was by then um she'd moved out of a home of 63 years and moved into a residential age care facility. That was her choice, and um we I'm the youngest of six, so there's a few of us, and we made a pact to visit her every day, which we did. Um, it was difficult because she was um really suffering emotionally. What actually happened um in the lead up was essentially I actually think her hip broke and then she fell. Her bones were just like chalk. So she was walking with one of my sisters and she was nearly back to her room, and she had did she have a fall and break her hip, or did she break her hip and have a fall? It's we'll never know. So I was surprised to realise that operative, um, that an operative approach would even be considered. It just seemed for somebody so old and so frail, um, I I just I guess I imagined her being cared for in bed without requiring an operation. Um my sister, who I shared, um the we'll we'll we were co-guardian, so we were both there for her health decisions. My sister's a registered nurse, so of course she was she was also my on-tap clinical um advice. I also had my colleague Hannah Seymour, who I definitely hit up for advice on more than one occasion. So I um I just want to just name that privilege of as a systemic advocate. You know, I I do understand the system in a way better than others. But so there we were. We had the we had the, you know, one of those really interesting things is capacity. Like my mother was very mentally um alert. Um she had she didn't have any dementia at all. So obviously the two of us being co-EPGs was was just academic because mum had capacity. And and yet, of course, when she was in all that pain, sitting for 24 hours in emergency, um, she it was quite hard to for her to even talk. So it was really about you know trying we we would be negotiating with the care providers and also trying to make sure we could hear what mum was saying or what she wanted. Um so yeah, I had I'd wrapped my head around the fact that yes, okay, she was going to have surgery, and then of course, as you can imagine, the care team were really concerned about putting my mum under a general. She was so frail, she was about 47 kilos by then. And so at one point in all the tooing and froing about surgical options, uh, a doctor came to her bedside and said, would she like a pacemaker? And my I instantly said no. And my sister, who's a registered nurse, thought maybe things had moved on from when she was practicing and there was some kind of less invasive um pacemaker process that had come on stream since she was there last. And and then when she realized that it was a pacemaker pacemaker, she was like, Oh, okay. At that point, I went home, and before I'd made the half-hour journey home, my sister messaged me and said, Mum wants the pacemaker, and I thought it was just one of those many huge lessons in humility I got as a consumer advocate because I would not choose that for my mother. My mother never ever wanted any kind of intervention when she was healthy and well. Um, but you know, as she said to my sister, when you think it's going to be your last night on earth, you don't want it to be your last night on earth. But luckily, she also she also realized that she did not want a pacemaker. So that was one of those really interesting capacity decision, you know, moments. So you know, essentially the um decision was made that she would um have twilight sedation, I believe, um, and and the the surgery was carried out. So she did make it to the other side, but she she had a a stroke very shortly thereafter on the way back to the residential age care facility. And she was she wasn't mum again in the next sort of seven to ten days that she lived. I actually can't remember now. She died on the 27th of August in 2024. Um I she was not mum anymore, but she had lost her terrible angst that she had her uh existential angst that had really gripped her for a whole year had gone, she was singing, she was she was very happy, less sir. Um, but she wasn't her, and I you know she was much more unguarded, I think, perhaps, than she would have liked, but she's just very sweet and very singing. There was one night when she when we were quite worried because she was singing quite a lot, um, all night long, apparently, and um I sort of came in really early in the morning and and one of the carers said, Oh, only Margaret complains, but Margaret complains about everyone. And um, all the caregivers absolutely loved my mum, so they they just put up with her singing all night long. So um it was just the usual thing that eventually the morphine dose continued up until until she um very peacefully passed. And I think you know there's so many things, you know, as a child, as an adult child, there's so many things you think could we have done things differently? I mean, even rewinding back a year when she went in, if we could have got the discharge summary in a timely manner, could we have had a better family meeting? Could we have made sure her medications perhaps made her last year a little bit less miserable? You know, were could we have pushed for non-operative, should we have pushed for non-operative with her hip? And and did she really need that? There was uh it was I think it was 24 hours in um Charlie's, and so mum is almost unable to say anything, but she she was there was quite a lot of drug and alcohol patients beside her, and she said, Well, there's a man over here, and he doesn't seem to have too many words, in fact, just one word, and it rhymes with duck. So that was kind of the last night of her life on earth, just about was was um listening to that man going on, and you think, you know, of course, she had daughters hanging off each arm, she had so much support as people with family do have, so there was so much, you know, that was good about her care. But but I I guess you know, there's always that would it have been better if we could have just tucked her up in into her bed at the residential aged care facility. Um, I feel very blessed to have the opportunity as a systemic advocate to be going over this in a in a more systemic way, thinking about this from a broader level. And I and I know when I had a quick look at the research around non-operative methods, one of my great concerns is that when people are in residential aged care facilities, that they won't be given the pain relief that um that they might require for that kind of um pain. And and certainly one of the carers that the one of the registered nurses was really upset that they left left mum go day after day after day, and that they hadn't put the morphine on a little earlier. So um, you know, I there's all sorts of things, you ifs and buts and when's and and yet, you know, it's sort of like once it's done, you know, she had such a great life.
SPEAKER_00Thanks, Pip. I appreciate it. Pip, I think what your recount really highlights is the overwhelming experience of an unexpected hip fracture. And it's such a time-pressured environment to make all these big decisions, like, okay, your mom's fractured hip, but does she want a pacemaker? Like, what I just couldn't believe it offered that.
SPEAKER_01I'm like, oh really? And I I did wonder, you know, the pacemaker means that everyone's covered from a clinical perspective. But what if mama had gone on and on and on and on with the pacemaker that no one could turn off? Like that would have been horrendous.
SPEAKER_00Yeah, I think the zooming out and focusing on the patient and where is that patient actually going? And what does, you know, how can we give a supported, dignified death? I think that's often a thought that a lot of people don't want to lean into, but it's such an important thing. I guess um if if you're up for it, the only other thing I was going to ask is during that experience, what aspects of care and communication stood out as particularly helpful or whether things like I mean, we've touched on probably what could have been done differently, but any staff members or particular roles that you found were you know really fantastic supports for you in that journey?
SPEAKER_01It's it's really hard, there's just such a parade of people and they just come and go and come and go. Uh, that the guy that came and asked about the pacemaker, um I I I don't think I'd met him before. He just sort of randomly turned up, what about a pacemaker? And he, oh hi, nice to meet you. So I look, I don't know. I think I think the emergency department environment is is is very um pressured, and I think we all understand that. I think what what I felt, I felt sometimes ashamed um that I would always want to go for the least amount of intervention, and was I being ageist, and for my own personal view, I've I've I've already told my daughter, once I can no longer live at home, I will probably um have at least one chronic disease that will get signed off of VID. I'm I'm you know, planning to be well into my 90s before I do that. So so my own views, I I believe were colouring that, and that's that that carer-consumer divide again. It's not about what I want, it's about what mum wants. But I think that was often quite hard to determine. So look, it's I I did feel that my mother was really valued, that they were throwing everything at it, that they really looked after her, that they really um took those difficult decisions, like you could almost feel the wrestling, like, yes, we've got to do it operative, but how on earth do we do this for this nearly 98-year-old weighing 47 kilos? How do we actually do this? And yeah, and I I just think I I really felt like it must be other options that that would give her comfort and and good end of days than this, but it it it it was not to be the case. It never for me, it never seemed to be an option that she would get up and walk again. Like I she was just so frail and so old and so tired. And yet, like she said, when you think it's gonna be your last night on earth, you don't want it to be your last night on earth. And that's that's I think a really perfect example of the complexity of end-of-life care.
SPEAKER_00I think it speaks volumes for the beautiful life Jim must have lived as well. So, I mean, Pip, thank you so much for sharing that journey. It's incredibly powerful to hear, yeah, incredibly valuable for clinicians listening to keep that focus in our minds. Um, I guess it also provides a nice segue into talking about where is the role for non-operative management of patients and what are we currently doing in Australia?
SPEAKER_02I've have really been interested in this for a very long time because I meet a number of patients and we work with a big multidisciplinary team. And often we look at people who come in with a fracture and we have conversations with people like Pip about what were her mother's wishes, or we ask people what they want. And we know that a group of patients' outcomes are very poor. I've previously talked on the podcast about our clinical frailty scale predicting mortality, and we know that people who have a clinical frailty scale of six or seven, half of them won't be alive at 12 months. So when we take that very frail group and we know that their outcomes are poor, we are trying to make the best decision that we can with them and their family about what is the right approach now that they've had a hip fracture. And we also know from experience that people who don't have an operation have a lot of pain, and people often described it to me as the most painful thing that has ever happened in their entire life. So, as Pip described, her mum was lying in emergency, having lived for 97 years with the most excruciating pain. And that influences people's decision making. So, although we know that people's outcomes are poor at 12 months, 12 months is a long time. And we know that lots of different things can happen over that period of time, and we also know that half of those people are still alive at 12 months, and I think some of those of us with lots of experience know that we're actually less good at predicting what will happen to people than we think. So we're left with some statistics that help us guide a conversation with a patient and their family about what is the best thing for them in their current situation. And the reason that the reason for non-operative management tag was changed in 2021 was because we wanted to look at this question. So back in 2018-2019, we had discussions in the data committee about why were people not getting operated on? And we realized that we didn't know because we didn't actually record the reason for non-operative management. So the first step in this study was actually adding that question. And then when we had a couple of years worth of data, we offered that opportunity for somebody to do this study. And that's what Carla did was she took up this study. And what we wanted to answer was: was it consistent across Australia? So across Australia and New Zealand, were we consistent in the number of people who had non-operative management and the reasons for those? And that was to help us answer the question as oh, are we even starting from the same point? And what questions do we need to ask next? So I see this study as a discovery process of are we consistent? And I think Carla can answer that. And of the patients who aren't having operations for palliative reasons, I think when you talk to lots of clinicians, most of us use the term actively dying. So if we think that somebody is actively dying, then we generally think that it's better just to offer palliative management because we think people are going to die quite quickly and they're not going to have a prolonged period in pain from a hip fracture. However, we also offer palliative operations. And what Pip, I think, described is someone who I think we offered a palliative operation. We had no illusions that her mum was going to be back to who she was the week before, even. But the amount of pain that she was in meant that managing her without pain was going to be really difficult if we didn't do an operation. And we also felt that if we palliated her and didn't operate, that she wasn't going to deteriorate very predictably quickly, and therefore wasn't maybe not going to die quickly. And that's what we worry about is that people are then left in this limbo having not had an operation, wondering if we've done the right thing. And I've had patients who we've palliated who come back and had an operation a week or two later because they haven't died. So I think those were the sort of questions that we wanted to answer by adding that box into the registry questions and then by getting this data to do the study. And so that's why Carla, who worked with me at the time and needed an advanced trainee project, took on this project because it was something she also was passionate about. Because we want to be able to start thinking differently about how we share information with families so that they have the information, the best information that they can at a very difficult time to try and make the best decision that we can in that situation.
SPEAKER_00Great. Thank you, Hannah. And while we I guess before I move on, I just wanted to ask for these patients that are actively dying or that we think are actively dying, what are we looking at? Who who typically fits that bill?
SPEAKER_02So they're often people who have another illness, acute illness, as well as a hip fracture. So they are people who often come in having had a stroke and a hip fracture at the same time. They may be people who have pneumonia, aspiration pneumonia at the same time as a hip fracture, or a group of people who are really, really exceptionally frail and at the real end of life. So at the real extreme end of that frailty scale, who are very malnourished and not really getting out of bed and may have severe dementia. So I think they're the patients who we think of as actively dying, but it is mainly those people who come in who have another comorbidity that is acutely deteriorated at the same time as their hip fracture.
SPEAKER_00Thank you. That helps clarify. So I'll bring you in, Carla. I mean, can we chat a bit about your study that explores the current practice in Australia and New Zealand for patients who are managed non-operatively after hip fracture? It's an area that's sometimes considered a bit outside of the usual surgical focus that we have with hip fracture, but could you briefly explain your cohort and what prompted this work?
SPEAKER_03Thanks for sharing. And it's stories like Pip's Mum that inspired this study, really. We know that a lot of you know it's a hip fracture cohort of patients that come up extremely frail, and it's about doing the right thing for them, which is patient-centred. But there wasn't much literature around what was currently happening here in the Australian War Museum. So the study was a retrospective registry-based study, included using the Australian War Museum and Factor Registry data. And what we looked at were the patient of fracture characteristics of those operated on and then not operated on. And in those who were not operated on, they were further divided into the palliative group, not operated because it wasn't clinically appropriate group, and an other group which were difficult to define.
SPEAKER_00If we were to zoom out and kind of summarize the key findings of the study, were there any results that surprised you or challenged existing assumptions about non-operative care, or what does the Australian and New Zealand landscape look like, just as a general overview in this picture?
SPEAKER_03Of those who were palliated, what we saw was that they were a much frailer cohort who were much more likely to come from residential care and be more comorbid, as well as more dependent on a And more likely to be men also. Of those patients who were palliated, and when we say that it was people who we thought were actively dying and not likely to survive and operational who were going to die quite quickly, we saw that the vast majority died in hospital with a number returning to their residential aged care facilities to die, and that the vast majority of those did die quite early, as we expect as we were expecting. However, there were a small number of patients who survived in that cohort, and that was around 6% at a year. What we don't know is what the quality of life or death was of those patients who survived despite being palliated. And I think that's an area that we really need to look into in more depth. They tended to be younger, less frail, less dependent. And they had similar outcomes to those who were operated upon, including ability to go home, length of stay, and mortality, which we would expect. And a large influencer for those who were not operated on because it wasn't clinically indicated was the fracture type, with non-display subcapital fracture patterns being more likely to be non-operated on. And that's well accepted in the literature. And looking at the patient characteristics, they looked similar to those who were operated on, but their outcomes were a bit different. Which raised questions for us whether it was that people were miscoding, or maybe this was a cohort of people who had declined an operation and it was a sort of a patient choice rather than clinically led. But that is an educated guess, and I have nothing to like evidence that. But I am aware that the hip fracture registry are going to add uh patient declined and operation as a reason for non-operative management based off of this study.
SPEAKER_00This I guess the scariest thing about not proceeding with an operation is those patients who we think are actively dying and then they're not. Actually, when you said one year, I was like, wow, they make it to one year. But that's the surprising the majority that we do get right. How long are they surviving with a hip fraction?
SPEAKER_03Yeah, so the mortality rates were taken at 30 days, 120 days, and a year. And so 87% had passed at the 30-day um mark. So the vast majority did die quite early. And then um, but then there was about 7% surviving to 120 days, and then about 6% to a year. Um, so I think that reflects that on the whole we are good at identifying people who are actively dying. Um and the vast majority of those do die quite quickly. What surprised me was that it was as many as 6% out to a year. Um and I that does feed into that worry that you're whether you're making the right decision for that person in front of you or not. And if you don't operate and they survive, what does that look like? And I think that's um an area uh of interest for research.
SPEAKER_00I guess that what we also don't know is if they were initially palliated, if they got pulled out of that palliation to go have a surgery at 30 days or maybe sooner. Um, we we probably don't know that from your study, but it would be interesting to find out. Yeah. Yeah. Yeah. Thank you, Carlos. In practice, both Hannah and Carla, how has this study changed your practice or how has it changed your approach to managing these patients who are a bit more complex and the decision isn't so straightforward to proceed with surgery?
SPEAKER_02I think it's a complex decision, and I think it needs to be made with senior people. So I think what Pip and her mum experienced is what lots of patients experience, which is a junior member of staff admitting the patient, talking about our standard of care, which is generally in operation, and someone questioning it, and that then needing to be a senior conversation. So I think this is where orthogeriatricians are really important because I think we have the overview of what happens. I have some orthopedic colleagues who are surprisingly good at predicting the patients who do poorly and actually do refer to us and are quite comfortable having that conversation. I have other orthopedic colleagues who are really not comfortable having this conversation with patients and their family. So I think having the data is really helpful because it gives me information which helps me inform people about what the options are so that we can make that shared decision. So I think that is how I take this situation now. I have this information. I know that most of the time when we predict that we are going to have somebody who is going to die relatively quickly, that happens, but occasionally it doesn't. And I think it's always important because the first question I get asked by people and their families, if we palliate someone, is how long is that going to take? How long is it going to take me to die? And that is a question which is really difficult to answer. What I usually say is, I think it can be usually within days, but occasionally we're wrong, and occasionally it takes longer, or we can change our views if something changes. Because this data does confirm that, that sometimes people do survive who we think are going to die. And as doctors, I think we're not as good at predicting outcomes as we think, despite much experience. As you know, Neve, I've been on this podcast a few times. I think we've calculated that I've looked after about 4,000 people with a hip fracture at Fiona Stanley Hospital, um, either directly or indirectly over the last 12 years because of our volumes. So, you know, you do get a real feel when you're looking after a high volume of people for what is likely to happen, but we're all wrong sometimes. And it is really hard to predict, and that makes it really difficult in situations like Pips, with you know, someone who they have loved and have a different view of to how they present in the bed in front of us with a hip fracture. And that is the situation that can be really difficult. And I think what is important over years of care with people like Pip and her mum is I can't be in their shoes, but I can give them information that helps make a decision because we have to make a decision one way or the other, because we're in this situation where someone is lying in front of us with a hip fracture, and that's not a really, you know, that's often some sometimes the most traumatic thing that's happened to people in their entire life, and that's really distressing for everybody. So, what you can do is bring a bit of calm and some information that allows us to make decisions together that we think is in the best interests of that patient and their family, and that's the best that we can do. And sometimes we get it as Pip experienced, you know. I think that's when we really think, gosh, did we do the right thing? When someone has surgery and really quickly deteriorates, and we all look back and we go, did we do the right thing today? Was that the right decision? And I think it's particularly difficult when that's your only experience. So for Pip, that's her only experience. Whereas as clinicians, we look after big volumes of people, and so we see every situation and feel more comfortable that we did still make the right decision, but it's really important that we question it all the time, and that's what we were trying to do with this study was answer the question of are we doing the right thing most of the time?
SPEAKER_00Thanks, Hannah. That's incredibly brilliant uh to take on board and yeah, a very, very difficult thing to reflect on, really, and sit with. Um, Hannah, how does this research translate to the global community in terms of taking your hat with the Fragility Fracture Network? How do we see Australian and New Zealand practice compare to what happens internationally?
SPEAKER_02Thanks, Steve. So that I think has been one of the most interesting things about thinking about this population of very frail people over the last couple of years. When I go to international meetings, you experience how much of this is related to ethical, moral, cultural issues around society in different places in the world. And Australia is definitely more comfortable having conversations about end of life. We have voluntary-assisted dying in every state now. We are having those conversations much more in the community than some of our colleagues in Latin America or Asia, where talking about dying is still not normalized and attitudes to end of life are very, very different. So, you know, if you talk about Australia and where do we sit, we definitely sit at a more palliative voluntary assisted dying end of the cultural spectrum. And there was a study in the Netherlands where voluntary assisted dying is much has been around for a bit longer, and there are much more conversations about that, that did spark some of this study where they looked at palliating people at the end of their life with dementia from a nursing home. What I learned when I went to FFN was how they do that. And that the way that people are palliated in the Netherlands is different to how we would palliate people in in Australia. So I think even within this group of countries where we talk about dying, where talking about end of life is culturally acceptable, we have very different ways of doing that. You only understand when you really get down to the detail of some of these small studies. So I think what we've tried to do now is we've started doing another consensus paper. So you remember the consensus paper on DOACs. So we're going through another consensus process around end-of-life care for people with hip fracture and operative versus non-operative management and the reasons for that. And we'd love to come back and talk about that in the future.
SPEAKER_00You know, we'd love to have you back here, Hannah. Thank you. Um so, I mean, thank you for giving us some insight into the current landscape in Australia. And it's actually surprising to hear that we're we're better at having the conversation than um than other countries necessarily, because I feel like the the general feeling is that we're not great at having these conversations and that you know no one's very comfy in those conversations in terms of clinicians, patients, and families alike. But it's nice to hear that maybe we are doing not such a bad job. Um, to finish, what is one practical thing clinicians involved in hip fracture care could do differently tomorrow to support patients who m may not be managed operatively? I was hoping to get a point from each of you if if you do have one to share.
SPEAKER_01Sure, I think you know, uh reflecting on on this conversation and trying to translate it back, I guess, to a um consumer carer perspective. I think about um, I think in many ways I feel some piece that yes, we did make the right call. I I think what I would have loved to have had as a carer is some kind of um, you know, sort of like these are the optimal care pathways and and why, some sort of information that was easy and um appropriate to the time as each thing was unfolding, a little bit more information to help make a decision. I also wanted to reflect on what it meant with my mother dying within two weeks before. So, of course, it was a sentinel event and and the forensic police got involved and and again because I was an advocate, I knew that I could refuse a um a full um autopsy, which my mother I absolutely was very clear was not what she would have wanted in any way, shape, or form. And and I guess that was again, I had that knowledge, so I I knew it would happen. I knew to put the funeral a little bit further out. Um I knew that we could say no to that. What was so interesting to me and surreal and horrible was sitting up in the funeral parlour with the with the forensic policewoman. She said, so she refused a pacemaker, as if as if my mother just didn't have enough, you know, gash and and desire to live. But uh that was that was one of those very strange things where it does feel like society is very pushable about the end of life thing. Um but yes, as I say, just that that um time relevant information as a carer, if you could have that to help you um make those decisions in this time. And and I I personally think I I feel like a sentinel event for my mum. I don't know, it just seemed like a bit of a waste of resources, but of course I'm I think it's very important that vulnerable people are, you know, that we're keeping an eye on vulnerable people passing. But yeah, there's there's a balance to be struck, perhaps. But yes, I'd love if I could just wrap up. It's it's information that turns these insights into these are your choice points. Um I would not have one of my mum to die in hospital. It was better to die in a resie age care, and we made that possible, and she was able to be there without terrible pain because she'd had the operation.
SPEAKER_00Thanks, Pip. I'll let try and include some resources as well in the bio for clinicians to be reminded to exist and please give to your patients. Um, but I think your point also highlights the importance of not just focusing on a long life, but also thinking about how do we provide a dignified death. That's really should also be at the forefront of our minds. Um, Carla, did you have a key message to leave?
SPEAKER_03I think it sort of reflects what Pip's already said is about not shying away from these difficult conversations as a as a medic or as a clinician looking after these patients and really bringing, you know, families into that decision making and being very honest and transparent about what the options are and what the pros and cons are of each of those options. Um, because I think that the family know that patient better than or that person better than you ever could. They've known them their whole life. And I think you really need to capture what's important to that pay that person and to their family before, you know, very complex decision-making conversations and trying as best as you can to come to a shared agreement with a very realistic view of what the future might look like.
SPEAKER_02So I agree with everything that Carlos and Piv have said. I think from a registry perspective, I might take a slightly different perspective. From a registry perspective, it's really important that we use the information that we have from people who've experienced a hip fracture to continue to improve their care. And that's the whole goal of the registry. And I think that this study is a really good example of the registry, taking a look at the questions that we ask, adding additional questions to really clarify what was happening and then taking the time to look at that data and actually use it to further inform people's care. And that is the whole point of the registry and why we do this every day.
SPEAKER_01Can I just add one more point from an advocacy perspective? I'd love to see more um patient-reported outcome or care-reported outcome measures over time and ideally co-designed with you know patients and families, that um this data wouldn't be missing, that there would be some richness to the data of what happens after the after the decision is made.
SPEAKER_00Beautiful. I mean, that's the whole reason we do this work is to try and improve the patient journey. It doesn't make much sense if we um can't get those perspectives. So absolutely. Thank you all for joining and specifically, Pip, thank you so much for sharing your mother's journey with us. It was phenomenal and it just provides such awesome perspective and context for what we're doing. Um, so thank you all for joining today. Please um have a look in our bio for the resources mentioned in the episode, and we'll see you again next time when you've come on Hipcast. Thank you. Thank you.